Intracerebellar coccidioidal granuloma.

A 45-year-old diabetic man was admitted for an episode of diabetic ketoac idosis that resolved quickly. During hospitalization, the patient stated that he had had left leg weakness and sensory deficit causing difficulty in walking for 3 years. Neurologic examination revealed normal motor and cran ial nerve functions, as well as normal reflexes and mental status. There was a sensory deficit below the left ankle. Ataxia and poor coordination of the left extremities suggested a cerebellar lesion. There were no c linical signs of meningitis. Cerebrospinal f luid was negative for smears and cultures. Head CT showed a low-density abnormality in the left cerebellar hemisphere with ring enhancement after contrast admin istration (figs. 1 A and 1 B). Metrizamide c isternography showed most of this mass to be intraaxial, with only a slight extraaxial component (fig. 1 C). Cerebral ang iography revealed on ly slight mass effect and stretch ing of the vein of the lateral recess of the fourth ventricle (fig . 1 D). Admission chest film showed a fluffy left upper lobe infiltrate (fig. 1 E). Sputum and needle aspirate showed no malignant ce ll s. Open biopsy of this lesion showed caseat ing granulomata with fungal elements strongly suggest ive of coccidioidomycosis. Craniotomy confirmed the CT findings of an intracerebellar lesion. Histology of the excised tissue showed a granulomatous process with fungal elements pathognomonic of cocc idioidomycosis [1] (fig. 1 F). Tissue from the craniotomy was cultured and grew a fungus that was ident ified later as coccidioidomycosis. The patient was treated with both intravenous and intrathecal amphotericin B. Recovery was gradual but uneventful.